Ankylosing spondylitis has a very high incidence in India and China. Unfortunately medical treatment is not that effective for Ankylosing spondylitis as for other inflammatory disorders like Rheumatoid. Drugs like Methrotrexate and leflunamide which are invaluable in the mgmt. of RA is practically useless in Ankspon Further the pattern of Ankylosing spondylitis in India and china is different from that of western countries. The involvement is predominantly in the spine/ hips and SI joint with relative sparing of other joints
The cornerstone of treatment of the Asian variety of Ank Spon is activity, more activity and much more activity. If the patient is very active by swimming, running ,doing sports, Yoga etc the spinal involvement can be arrested, maintained and to a significant degree reversed
However if the patient has symptomatic hip disease can interfere with the activity level of the patient and make him or her sedentary. This in turn accelerates the spinal disease of Ank Spon. The surgeon must help the patient at the appropriate time by doing a functional arthroplasty of the hip , so that the restored functional capacity of the patient will prevent the progression and reverse the spinal component of the spinal disease
If left till the late stg the hip can go to complete fusion. While a fusion take down is technically possible, it is best to intervene before fusion occurs as it makes the surgery far simpler to perform
Our unit has the largest experience of hip surgery in Anklylosing spondylitis in India > 700 patients. The technical problem with surgery in ank spon. Is the presence of osteoporosis ( weak bone ) in the young patient. Commonly weak ostorporotic bone is seen in the elderly post menopausal female patients. This is easily managed by using bone cement and a cemented component. This strategy is ill advised in the young patient as cemented hips are difficult to revise needing and osteotomy for revision.
Dr. Bose has developed a technique of using the patients own femoral head bone as bone graft in the proximal femur. This enables the adoption of bone conserving implants like the corail in these osteoportic but young patients. This makes any revision surgery ( if required ) very easy to do. This combines with wear resistant options like deltaceramic on deltaceramic addresses the issues of ank spon perfectly
The other strategy of dealing with osteoporosis in the young pt. is the use of highly porous material like Gription. One example is the Trilock stem. An example is shown below.
The 3rd strategy of dealing with osteoporosis in the young patient is by using the BMHR. (Birmingham Mid Head prosthesis)
Ank spon with bilateral fused SI joints:
Can be a crippling disease in very young patients. End stage affliction of the joint can make the patient wheelchair bound. Since long lasting wear resistant articulations are now available one can restore a normal adolescence and lifestyle in these patients.
12 years old SLE with a deltamotion hip:
JRA is another crippling disorder which can rob a patient of his or her childhood. Excellent medical treatment is now available for RA and thus end stage RA with complete destruction of the joint is rare these days. However the potency of the disease can be so overwhelming that end stage joint destruction occurs before the drugs can act effectively. In these patients joint reconstructive surgery using bone sparing options is a viable alternative today.
11 years old patient with hip resurfacing:
Medical treatment in RA is very effective and patient can manage with the same for years.
However they may develop secondary osteoarthritis at a later stage which can be very symptomatic.
Surgeries which can restore full function is now available.
53 year old RA patient showing functional level post bilateral hip surgery.